John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I love the never ending discussion of the number of mouseclicks and keystrokes that an EHR requires. I’ve heard this discussion for all 6+ years I’ve been blogging about EMR. While I don’t want to make an excuse for EHR companies to create crappy software, I think that there’s a few problems with just stating that an EHR software has too many clicks. Let’s take a deeper dive into the idea of too many clicks and keystrokes in an EHR software.

I once heard in a discussion the comparison of a piano player being able to quickly tap out a song on a piano with a doctor tapping and clicking out his medical notes in an EHR. They then posed the question, “Why can a piano player easily play so many notes so quickly?”

It’s an insightful question and comparison which I believe could help an EHR vendor deal with the issue of too many “EHR mouseclicks and keystrokes. As I think about why it’s not a burden for a piano player to play so many notes so quickly, I think it boils down to two areas: responsiveness and training.

One of the unique characteristics of a piano is that as soon as you tap the key, it makes a sound. Imagine trying to play the piano if when you tapped the key sometimes it would instantly make a sound and other times there’s a slight half a second or one second delay. It would be impossible to play a song and to get a rhythm that would allow you to play so many notes so quickly.

Unfortunately, the terrible situation I described above is what we experience with EHR software. Sometimes when you click you get an instant response and sometimes when you click you have to wait a little bit. The same goes with a keyboard on a computer. I recently had a bug on my computer that would basically tie up all the memory on my computer. When that happened I could type, but the letters would show up on the screen at varying intervals. I’m a pretty fast typer, but when this was happening it was terrible. I had to just stop until the problem was resolved.

While I’d love to just say that an EHR should always respond instantly to any request made, that’s not reasonable. The key for EHR vendors to think about is doing everything they can to ensure that their EHR responds in a consistent manner. The faster the better for sure, but don’t undervalue the benefit of a consistent response.

The second piece of this puzzle is training. We don’t assume that someone can step up to a piano and play all the right notes to a complicated piece of music with no training. Yet, for some reason we think that a doctor can step up to a complicated piece of software (EHR for those following at home) and quickly navigate all of the features of the software. Training matters and can make the world of difference in how you feel about the number of “clicks” you have to do in your EHR.

I’m sure that many EHR vendors love the above paragraph, but they also see the reality of many doctors not wanting to take the time or make the effort to train on an EHR properly. Doctors reasonably offer that they can’t just shut the doors on their clinic for a week of EHR training. While the politicians in DC can’t seem to do this, the solution to these two extremes is somewhere in the middle.

I’m not naive to the challenges that we face with click happy EHR systems. I’m certain that every EHR software could improve its software to decrease the number of clicks and make them more intuitive. I’m also certain that there are many doctors that don’t and won’t train themselves on the EHR software. Instead, they’ll sit back and blame their lack of training on “too many clicks.”

I have little doubt that both sides of the equation could and will get better. EHR software will become less click happy. Doctors will become better at clicking quickly. Although, until the software captures are thoughts automagically, we’re going to continue battling with these issues.

13 responses to "Too Many EHR Mouseclicks and Keystrokes – A Solution for EHR Vendors"

“The actual charting of a simple straight forward pediatric encounter only takes 37 seconds, from start to end. One pediatrician I know famously says “If I can’t chart a routine otitis media encounter in under 30 seconds, I know something is wrong!” (As in, the server is slow today, tell someone to fix whatever needs to be fixed.)

By the way, the comment that using a finger instead of a mouse takes only a third of the 37 observed seconds only initially seems implausible. There are 17 clicks. Can you tap your finger 17 times in 12 seconds? Certainly you can. Wait, you protest, what about tapping a finger in *different* places? Nope, can still be done in 12 seconds. Musicians do this sort of thing all the time. As noted in a previous post, the cognitive motor skills necessary for data entry in a pediatric EMR workflow system more resemble that of a piano player than a knowledge worker. (By the way, I’m planning on a future post that critiques EMR data and order entry from the point of view of psychological models of musical cognition, learning, and motor skill.)”

Some of the stuff I write and tweet about is more popular overseas than in the US. For example, there’s lots of interesting content about healthcare BPM in Dutch and German. I often run tweets and webpages through Google Translate.

Take the above mention of this post in a Spanish language blog. I don’t speak Spanish (wish I did, my wife does), so I’ve relied on Google Translate, again, to follow someone blogging about this conversation on EHRs, clicks, and usability:

…drilled back down to my own 2009 post about EHR Featuritis, where I mention the analogy between EHR data/order entry and playing a musical instrument. (My comments are in “[ ]”s. And, obviously, any lack of grammaticality is due to automated translation, not the original Spanish text.)

“In the blog ‘EMR and EHR’ [this, @TechGuy’s, blog] we saw this post about the abuse of clicks and number of operations that must be done to navigate traditional electronic medical records. And from the comments we got to this other post on ‘Electronic Health Record Workflow Management Systems’ [my, @EHRworkflow’s, blog]”

We found it very clear how they use the term “featuritis” (or its synonym “feature creep” …) to define the problem. The featuritis is a “swelling” of the features, functions of the system are situations where you add dozens of functions to the system because they “have to be” without coordinating with each other, and without a plan on how to provide an experience of orderly and clear user.”

A lot of well meaning people overloaded the current generation of certified EHRs with “dozens of functions…because they ‘have to be’ without coordinating with each other.”

There’s a fundamentally important connection between patient care coordination and coordination technology such as business process management, adaptive case management, process-aware and context-aware mobile and social in the cloud. While many current EHRs and HIT systems aren’t hoary 30-year-old COBOL applications, they are, in their own way, an unfortunate legacy that is weighing us all down.

There’s so much finger pointing going on. The government did it. The vendors did it. The users did it (to themselves!). The problem isn’t people, it’s technology. Let’s not lock ourselves into software with frozen workflows. Adopt modern process-aware (health) information systems.

I love how, between the Web and free translation services, the world really is getting smaller and smaller. Smarter and smarter too, I hope.

Charles, John, thanks! we were discussing this subject inside the team, we even posted an update in our blog detailing our thinking behing some small updates we did in our free web based EMR system and how those updates reduced the click count, and one of my colleagues found your posts.

I believe that explaining this thinking to the users is also key to usability, like when you talk about training, not everything will be obvious. Having some text in a coloquial, passionate and human form, that introduces the users to the tool and the philosophy behing it, is really important.

Thanks for posting such interesting information! and let’s keep the collaboration going…

This overlooked but costly clinical data management problem may finally be solved by an unprecedented series of interrelated events. These include the move from fee-for-service to fee-for-value and financially accountable care, the huge increase in competing EHR products since 2009 and growing physician demands for redesigning EHRs to significantly improve usability and utility.

Doctors, like everyone else, have limited brain RAM. If we use it up trying to figure out what’s going on on the screen then we force some critical piece of information out of our minds. It’s more about working memory than click counts. It’s just you can measure click counts, and you can’t measure working memory.

Developers can use all their RAM looking at the screen. For doctors, what’s on the screen is only a small part of the encounter.

[…] to “having to do SOOOO many clicks.” (emphasis theirs) I still love the analogy of EHR clicks compared to playing a piano, but unfortunately EHR vendors haven’t done a good job solving the two things described in […]

[…] an interesting word to describe EHR usability. I’ve written about this topic before when I compared the number of EHR clicks to the keys on a piano. In that article I suggested that the number of clicks wasn’t the core issue. If we could […]